By Sriparna Roy and Sneha S K
March 12 (Reuters) – Artificial intelligence is being deployed on both sides of the tug-of-war between U.S. healthcare systems that want to be paid more for medical procedures and insurers who want proof the services were necessary, and experts are having a hard time predicting a winner.
Centene, an insurer focused on the Medicaid program for low-income people, recently raised the issue, saying hospitals were aggressively or even improperly using revenue software to trigger reimbursement.
“There have been some of these pockets where folks coming into the emergency department with a fever, all of a sudden all have sepsis,” Centene CEO Sarah London said at a September investor conference, referring to a life-threatening condition that triggers a host of medical interventions.
A Blue Cross Blue Shield analysis of its commercial hospital claims found that roughly $663 million in inpatient spending and at least $1.67 billion in outpatient spending may be tied to more aggressive, AI-enabled coding practices nationwide.
“We are seeing more AI tools used at different points in the care and billing process, and when those tools operate independently, they can unintentionally lead to friction,” said Razia Hashmi, vice president of clinical affairs at Blue Cross Blue Shield Association.
AIM TO DRIVE DOWN COSTS
In recent months, some health insurers have increased reliance on AI to help catch treatments and bills they say are unwarranted, even as hospitals use AI tools to document those medical services with codes that boost reimbursement, a review of company statements and interviews with a dozen experts and analysts found.
The U.S. spends more on healthcare than any other nation at about 18% of its gross domestic product.
Both sides hope AI will drive down costs. Consultancy firm McKinsey estimates that for every $10 billion in revenue, AI could save insurers $970 million through claims management, medical prior authorization requests and by guiding clinical care.
AI tools are already leading to hospital care savings and they could amount to as much as $900 billion by 2050, Morgan Stanley said in a September research note.
“The idea of (AI) bot versus bot is intrinsically a situation where no one’s going to win,” said Christina Silcox, research director of digital health at Duke-Margolis Institute for Health Policy.
COMPANIES PLAN SAVINGS
Several analysts, including TD Cowen’s Ryan Langston and Whit Mayo of Leerink Partners, said insurers and hospitals could save money by using AI, but they did not provide estimates. Companies are also using AI widely for administrative tasks.
